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DSM-IV TR, which stands for Diagnostic and Statistical Manual of Mental Disorders (4th edition), Text Revision was published by the American Psychiatric Association in 2000 and serves as a guide book for many health professionals to diagnose a patient with a mental disorder. It also helps health professionals to determine what types of treatment could be carried out to help the patient. The latest DSM is widely used, especially in the USA and many European countries.1However, it may not be completely followed by health professionals as they know that there are some weaknesses of the latest version of DSM as well.
This essay will discuss the strengths and the weaknesses of the latest DSM and new changes for the DSM-V, which is expected to be published in May, 2013.
DSM's strength would be that it standardizes psychiatric diagnostic categories and criteria2, making the diagnosis of a mental disorder relatively easier than it was in the past. It allows health professionals to diagnose a patient, use the DSM to give them possibly the best treatment and overall, help them to cure the patients if the disorder is curable.
DSM also has statistical data such as the prevalence of a certain disease in different genders, age of onset of diseases, etc. This allows health professionals to have a very wide range of knowledge which may be very useful for diagnosis and treatments. Besides, the DSM allows a common language for discussing diagnosis. It provides clear criteria for certain disorders so that every clinician would come up with the same diagnosis.
This makes sure that a person is not diagnosed with different types of disorders in different clinics.Thus, treating patients more efficiently.
Compared to the older versions of the DSM, the latest DSM also has more subtypes and specifiers which increases the diagnostic specificity. As I mentioned before, this increases the chance of diagnosing a patient with the same disorder in different clinics, assuring that they are diagnosed with the correct disorder as misdiagnosing them could possibly lead to serious damage.
For some disorders, such as bipolar disorder, there are severity indicators such as mild, moderate and severe as well. This helps clinician to decide the course of the treatment according to the severity of their disorder. This is one of the strength of DSM as using the same treatment for different severity of the same disorder will not be very appropriate or efficient. However, this severity indicator is absent in some disorders such as manic episodes which is one of the weaknesses of DSM-IV TR.
These were some of the strengths of DSM-IV TR. However, we know that another edition of DSM, DSM-V is expected to be published soon. This is obviously because there are some, or many weaknesses in the current DSM with which people are not satisfied.
One of the major weakness of the current DSM and probably all the older editions is “Cultural Bias”. DSMs are mainly published by anglo-Americans and most of the behaviour that is considered as “normal” in the DSM is actually what is considered normal by the anglo-Americans. That is, some of the behaviour that is considered as abnormal in the DSM might be considered as normal in other cultures. For example, in some cultures, people tend to put a lot of emphasis and values filial piety and due to that, they would behave in a way that might not be considered as normal by the anglo-Americans. Would that classify them as abnormal? What exactly is normal anyways? According to the DSM, it it, I believe, what is considered as normal by the anglo-Americans. This is one of the weaknesses of the DSM which is well-known and I think it is because of this reason that DSM might not be as popular in countries where the culture is much different compared to countries like the USA and many European countries.
Another weakness would be that DSM promotes a mechanical approach to mental disorder assessment. The clinicians may focus excessively on the signs and symptoms of mental disorders and they might not put much emphasis on a more in-depth understanding of the clients/patients problems. This problem have improved but it is still a problem caused by the DSM. DSM-IV TR also does not consider patients subjective experience of a disorder. That is, the approach is not a dimensional approach as there is no first-person report but rather, observations are usually carried out which may neglect the more somatic and psychological processes that underlie the symptoms (Flanagan, Davidson & Strauss, 2007).3 Also, DSM causes most clinicians to be primarily concerned with the signs and symptoms of a disorder rather than the underlying cause by giving a list of certain criteria for diagnosis.
Another weakness and debate about the DSM is that it is an unscientific system and it is the opinion of a few powerful psychiatrists. This has raised a lot of questions and have caused people to question the validity and reliability of the diagnostic categories as well. The validity and reliability were especially questioned after the Rosenhan experiment in the 1970s in which it was concluded that the sane could not be distinguished from the insane in psychiatric hospitals. Thus, even though the reliability and validity has improved now when compared to the 1970s, it is still a weakness which I believe could not be entirely fixed. However, validity problems of the diagnostic criteria especially arise when children or adolescents are involved.
For example, the DSM-IV TR criteria for bipolar and manic disorder were originally developed for adults but right now, after a few changes, it is used for children as well. This increases the chance of misdiagnosing children with bipolar disorder. This information is supported by the fact that in the last 10 years, there has been a 40%4 increase in the number of children diagnosed with bipolar disorder. It is believed that there is not a sharp increase in the number of children with bipolar disorder but rather that the clinicians have been applying the diagnostic criteria (which were originally developed for adults) much more aggressively to children.5This is one of the weakness of DSM-IV TR that needs to be improved in the future as the effects could be devastating.
One of the weakness, which I believe is not very significant but still is a problem and which is actually questioned by people is the definition of the mental disorder. This was also mentioned in the lectures. According to DSM-IV TR, a mental disorder is “associated with present distress or disability or significant increased risk of death, pain, disability and important loss of freedom”. This raises the question.. what about those individuals who engage in activities that threatens their lives but they actually enjoy it? Such as mountain climbers, scuba divers, etc. Obviously they are no considered as abnormal but according to the definition of the DSM, they are considered as having a mental disorder. But we know that this is not correct. Thus, there is a problem with the definition of the word 'mental disorder'.
There are many other weaknesses as well such as with Personality Disorder diagnosis. It is believed that the description of symptoms is very broad. This means that patients diagnosed with the same disorder could actually have very different clinical presentations. For personality disorders, DSM uses a categorical approach6. However, it would be better to use a dimensional approach so that the different types/ degree of disorder could be distinguished and thus, could be given different and more efficient treatments.
Another major weakness of the Axis II personality disorder is that there is a very high degree of overlapping or co-occurence with each other. This is also a problem for Axis I mental disorders.7
There are many other weaknesses with specific disorders of DSM especially about the diagnosis criteria and some other issues such as whether 'Paraphilias' should be included or not. Most of the major ones has been discussed above. Now, the new changes for DSM-V will be discussed.
There are many new changes for the DSM-V. I will mainly mention those that are related to the weaknesses mentioned above. However, the new changes are discussed, the 4 principles behind the current process for revising DSM should be discussed. (Obtained from APA DSM-V Development's official website)
1) Clinical Utility- the manual should be useful to those who diagnose and treat patients with mental illnesses
2) Recommendations should be guided by evidence
3) DSM-V should maintain continuity with previous editions whenever possible
4) No priori restraints should be placed on the level of change permitted between DSM-IV and DSM-V
From these 4 principles, it becomes clearer to us why DSM-IV is being revised and what changes should be expected. One of the changes is that in order to better assess the severity of symptoms, a dimensional assessment will be included. For example, other factors such as sleep quality, mood, etc will be considered regardless of the diagnosis. This will help to reduce the problem of “mechanical approach” as mentioned before. They will also help to address symptoms that are not included within the diagnostic criteria for specific illnesses (e.g. the problem of insomnia for patients diagnosed with Schizophrenia).
DSM-V might also include something that could solve the problem of how to handle patients with co-occuring disorders, which is a major weakness of DSM-IV TR. Besides that, DSM-V will also have improved diagnostic criteria that are not precise in DSM-IV TR.
Also, a few words would be changed as well in the new DSM. For example, the word “Mental Retardation” would be changed to “Intellectual Disability”. Another change that would also be included would somehow, indirectly address the problem of cultural bias. In the new DSM, careful consideration would be given to the gender, race and ethnicity. This, I believe could help to lessen the severity of the cultural problem as mentioned before.
Besides that, another 'proposal' is that, the criteria should be more stringent for the diagnosis of bipolar disorder in children. This also addresses one of the weakness mentioned earlier. This is a very important proposal as I believe it is not very humane to misdiagnose children with “Mental Disorders”. It could affect their life significantly.
Another major changes is in the assessment and diagnosis of personality disorders. As mentioned before, a dimensional approach will be used rather than a categorical approach. This can help to determine the different severities of disorders and determine the 'subtypes' more accurately. Overall, it would make the diagnosis much more accurate and thus, more efficient treatment could be used.
These changes were mainly in response to the weaknesses mentioned above. Other changes include creating a new category called “Behavioural addiction”. This category is solely based on gambling. Internet addiction was also proposed. However, due to the lack of research in that field, it was rejected. This shows that they somehow followed principle 2 which emphasizes on the importance of evidence. Another category called the “Risk Syndromes” is also being considered. This will help clinicians identify earlier stage of mental disorders. The category of substance abuse and dependence will be removed and it would be replaced by a new category called “Addiction and Related Disorders”. This is done to help clinicians distinguish between similar types of disorders more easily and lower the chance of misdiagnosis (e.g. dependence is often confused with compulsive drug-seeking behaviour addiction). 8Another change is that the criteria for some eating disorders such as Anorexia Nervosa has been improved.
Overall, the diagnostic criteria for many disorders has been improved and a dimensional approach is being used in DSM-V rather than the categorical approach used in the previous editions. All of these changes, together with many other minor ones, aim to improve the diagnosis process and thus, ensures that people are saved from misdiagnosis (which could lead to devastating effects) and so that they can receive better treatment which would increase their chances of being cured (if the disorder is curable).
Berman, J. (n.d.). Understanding the DSM-IV TR. Retrieved on 15th March, 2013, from http://www.ceuschool.com/librarydocs/SOC222.pdf Dombeck, M., Hoermann, S., Zupanick, E.C. (2011). Personality Disorders: Problems with current diagnostic system. MentalHelp. Retrieved on 14th March, 2013, from http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=569 Flanagan, E., Davidson, L. & Strauss, J. (2007). “Issues for DSM-V: Incorporating
Patients’ Subjective Experiences.” Am. J. Psychiatry, 164(3), 391 – 392. Kleinplatz, P.J., Moser. C. (2005). DSM-IV-TR and the Paraphilias: An Argument for Removal. Retrieved on 14th March, 2013, from http://www2.hu-berlin.de/sexology/GESUND/ARCHIV/MoserKleinplatz.htm Kronemyer, D. (2009). Phenomenological Psychology. Retrieved on 14th March, 2013, from http://phenomenologicalpsychology.com/2009/06/how-can-dsm-iv-be-improved-as-it-transitions-to-dsm-v/ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC. Bipolar Disorder in Children. Wikipedia. Retrieved on 14th March, 2013, from http://en.wikipedia.org/wiki/Bipolar_disorder_in_children Diagnostic and Statistical Manual of Mental Disorders. Wikipedia. Retrieved on 14th March, 2013, from http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders DSM-5. Wikipedia. Retrieved on 14th March, 13 from http://en.wikipedia.org/wiki/DSM-5 DSM-5 development: Frequently Asked Questions. American Psychiatric Association.Retrieved on 14th March, 2013, from http://www.dsm5.org/pages/default.aspx Rosenhan Experiment. Wikipedia. Retrieved on 14th March, 2013, from http://en.wikipedia.org/wiki/Rosenhan_experiment
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